Topic in Geriatrics: Lumbar Spinal Stenosis & Chronic LBP
Objectives: 1. Explain some reasons why low back pain due to spinal stenosis is common amongst geriatric patients 2. Provide a typical presentation of a patient with spinal stenosis 3. Provide evidence based treatment recommendations for patients with spinal stenosis 4. Provide resources for addition information on spinal stenosis and treating the condition
Information about the topic: Lumbar stenosis is prevalent among the geriatric population, and is a common source of low back pain that is chronic. There are many causes of spinal stenosis that result from degenerative changes, which make older adults particularly susceptible to the condition. Some causes include the following:
facet joint degeneration
intervertebral disk degeneration
spondylolisthesis
thickening of spinal ligaments
surgery related fibrosis
Narrowing of the spinal canal causes neurogenic claudication, which presents as pain which may or may not radiate. Symptoms are made worse with standing, walking, and extending the back. Supine lying or flexing the spine relieves symptoms. On exam, patients often present ambulating with a wide base of support, and may have sensory or motor deficits in the lower extremities. Because these symptoms are shared with other potential causes of low back pain, a thorough exam is required. Additionally, it should be noted that hip osteoarthritis and vascular claudication are often present along with lumbar stenosis, and may compound symptoms.
Stenosis is the most common reason for spinal surgery in the United States. However, some geriatric patients are not candidates for surgery, or opt for conventional treatment. It has been found that patients who receive physical therapy initially have the same results as surgical patients, but eventually choose to have a spinal decompression surgery. A home exercise program may be necessary to maintain benefits gained in physical therapy.
Evidence based treatment:
A systematic review determined there is valid but limited evidence that physical therapy is an effective means of treating stenosis:
One study found that low intensity strengthening and stretching, along with low intensity cycling improved function and using ultrasound decreased pain levels for patients with stenosis. Another study compared epidural steroid injections with exercise for effectiveness of pain management. In this study, there was no significant difference between groups.
Distraction manipulation has also been proven effective for spinal stenosis, with clinically significant improvement in disability level, pain score, and overall self-rated improvement.
Lumbosacral corsets have been shown to increase walking time in patients with lumbar spinal stenosis. This method of decreasing lumbar weight bearing allowed patients to increase activity time prior to the onset of symptoms and also decreased pain scores. However, there is no evidence for maintaining improvements once the brace is doffed.
The current recommendation for stenosis treatment includes performing lumbar flexion exercises to treat pain, flexibility and strength training, and patient education. The goal of physical therapy should be to manage symptoms and maintain function. It is important to treat all contributors to the back pain and leg symptoms, keeping in mind that comorbidities may be contributing to their condition.
References 1. Fritz J, Rundell S, Weiner D, et al. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert- Based Recommendations for Evaluation and Treatment. Part VI: Lumbar Spinal Stenosis. Pain Medicine [serial online]. March 2016;17(3):501-510 10p. Available from: CINAHL Complete, Ipswich, MA. Accessed July 3, 2016.
2. Goren A, Yildiz N, Topuz O, et al. E cacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clin Rehabil. 2010;24(7):623-31.
3. Kreiner DS, Shaffer WO, Summers J, et al. Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. Burr Ridge, IL: North American Spine Society (NASS); 2007.
4. Maher CG. Re: Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31:2541-9. Spine. 2007;32(7):833; author reply 833-4.
5. Tomkins CC, Dimo KH, Forman HS, et al. Physical therapy treatment options for lumbar spinal stenosis. J Back Musculoske- let Rehabil. 2010;23(1):31-7.
Objectives:
1. Explain some reasons why low back pain due to spinal stenosis is common amongst geriatric patients
2. Provide a typical presentation of a patient with spinal stenosis
3. Provide evidence based treatment recommendations for patients with spinal stenosis
4. Provide resources for addition information on spinal stenosis and treating the condition
Information about the topic:
Lumbar stenosis is prevalent among the geriatric population, and is a common source of low back pain that is chronic. There are many causes of spinal stenosis that result from degenerative changes, which make older adults particularly susceptible to the condition. Some causes include the following:
Narrowing of the spinal canal causes neurogenic claudication, which presents as pain which may or may not radiate. Symptoms are made worse with standing, walking, and extending the back. Supine lying or flexing the spine relieves symptoms. On exam, patients often present ambulating with a wide base of support, and may have sensory or motor deficits in the lower extremities. Because these symptoms are shared with other potential causes of low back pain, a thorough exam is required. Additionally, it should be noted that hip osteoarthritis and vascular claudication are often present along with lumbar stenosis, and may compound symptoms.
Stenosis is the most common reason for spinal surgery in the United States. However, some geriatric patients are not candidates for surgery, or opt for conventional treatment. It has been found that patients who receive physical therapy initially have the same results as surgical patients, but eventually choose to have a spinal decompression surgery. A home exercise program may be necessary to maintain benefits gained in physical therapy.
Evidence based treatment:
A systematic review determined there is valid but limited evidence that physical therapy is an effective means of treating stenosis:
The current recommendation for stenosis treatment includes performing lumbar flexion exercises to treat pain, flexibility and strength training, and patient education. The goal of physical therapy should be to manage symptoms and maintain function. It is important to treat all contributors to the back pain and leg symptoms, keeping in mind that comorbidities may be contributing to their condition.
Resources
1. Exercises for spine health
http://www.spine-health.com/conditions/spinal-stenosis/exercises-lumbar-spinal-stenosis
2. General information about the condition and physical therapy treatment
http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=5e4daaa0-cb21-4eee-8484-e728617397aa
3. "Top 3 Exercises For Spinal Stenosis" Video - demonstration
https://www.youtube.com/watch?v=zYVGQwYfsKU
4. Treatment considerations to recommend PT vs surgery:
http://emedicine.medscape.com/article/1913265-treatment
5. Visual Aids for patient education
https://i.ytimg.com/vi/rMEkjGHZ7o0/maxresdefault.jpg
http://chronicpainreliefoptions.com/wp-content/uploads/2015/05/SpinalStenosis2.jpg
6. Home exercise program with illustration
http://www.johnyfit.com/wp-content/uploads/2016/02/spinal_stenosis_exercises.jpg
References
1. Fritz J, Rundell S, Weiner D, et al. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert- Based Recommendations for Evaluation and Treatment. Part VI: Lumbar Spinal Stenosis. Pain Medicine [serial online]. March 2016;17(3):501-510 10p. Available from: CINAHL Complete, Ipswich, MA. Accessed July 3, 2016.
2. Goren A, Yildiz N, Topuz O, et al. E cacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clin Rehabil. 2010;24(7):623-31.
3. Kreiner DS, Shaffer WO, Summers J, et al. Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. Burr Ridge, IL: North American Spine Society (NASS); 2007.
4. Maher CG. Re: Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31:2541-9. Spine. 2007;32(7):833; author reply 833-4.
5. Tomkins CC, Dimo KH, Forman HS, et al. Physical therapy treatment options for lumbar spinal stenosis. J Back Musculoske- let Rehabil. 2010;23(1):31-7.